What Is "Health"?

Americans do not know how to talk about health care, at least not civilly. For a politician, the mere utterance of the phrase can be political self-immolation. And the ash sticks. Even the little engine that could, the Patient Protection and Affordable Care Act (ACA), which passed both houses of Congress, survived a Supreme Court challenge, a national election cycle, and a government shutdown, continues to incite the country. So a book as well-researched and well-argued as The American Health Care Paradox, which offers Americans a fundamentally new, values-driven way to talk about health care, deserves to be purchased, read, and carefully discussed. In this work, Elizabeth H. Bradley, a professor of public health at Yale University and the director of the Global Health and Leadership Institute, and Lauren A. Taylor, a presidential scholar at Harvard Divinity School, offer a crucial addition to public deliberations on what is wrong with the American health care system. For them, the central concern is the longstanding division between what the country has come to call social services and health care.

The book opens with Joe, a man with diabetes, twenty-eight years old, wading through damp marshlands to sneak into a condemned home. The home is not even his; it belongs to a friend. Joe's income is erratic, his access to food unstable, and his shoes are mired with holes. To manage his type 1 diabetes, he needs to be mindful of his nutrition, his insulin, and his feet. Joe has already had two toes amputated after diabetes-related complications. The state medical assistance program covered the procedure for $7,132. Since he is finding it difficult to manage his nutrition and keep his feet dry, Joe's doctors believe two more toes will need to be removed, at a total of $14,430. And after that, if he continues to live under such precarious economic and physical circumstances, he may require a below-the-knee amputation, which will cost an additional $17,347. This is the American health care paradox. To stay healthy, Joe needs help securing a steady job and a place to live. His doctors can't treat those problems. What they can treat is his toes. As Bradley and Taylor put it: "Amid a system marked by the most advanced medical treatment in the world, Joe is dying a slow, painful, and expensive death. A decent pair of shoes costs $50" (1).

The American Health Care Paradox: Why Spending More Is Getting Us Less starts with a problem, offers an empirical diagnosis, and closes with a value-driven cure that should entice religious leaders and scholars. Since the 1970s, experts have recognized a discrepancy between the relative amount Americans spend on health care and the health results they receive. The United States currently spends $2.8 trillion on health care. That is approximately $8,000 per capita, as opposed to the $4,000 per capita spent by other industrialized countries. The soaring cost of health care is swallowing national and state budgets and forcing political leaders, business owners, and individual citizens to give more and more of their income over to health care. Not only is this model unsustainable, but worse, the costs are not even translating into results. Compared to similar countries, U.S. citizens have a shorter life expectancy and higher infant mortality, as well as greater rates of obesity, diabetes, heart disease, and disability. The enigma of American health care, as Bradley and Taylor reiterate, is that we "spend more" and still "get less" (2).

Scholars looking at this trend have offered a number of diagnoses. Some ascribe the problem to underinsurance, an issue the ACA hoped to solve. These thinkers believe that if all Americans were insured, costs would go down and results would go up. Bradley and Taylor are not convinced, writing, "data suggests that American health outcomes among insured populations still lag substantially behind those of other countries" (9). They are also skeptical of the arguments that the high costs are due to the effects of frivolous medical malpractice suits or inefficiencies that take place within a complex public-private system. Americans, these authors insist, might not be able to solve the health care paradox without completely rethinking the parameters of how health care is defined and discussed. Instead of pursuing a policy approach that seeks to fix health care on its own terms, they offer a way of looking at the problem that is at once eminently intuitive and completely radical.

Bradley and Taylor begin their investigation with a quantitative hunch: that the "exorbitantly high spending and relatively poor health outcomes . . . could be explained by examining a broader set of national expenditures" (xvi). Instead of fixating on the amount the United States spends on health care, they began by collecting data on spending and health outcomes from thirty peer countries. Their study revealed a somewhat astonishing fact. In the authors' words, "if we counted countries' combined investment in health care and social services, the United States was no longer spending the largest percentage of GDP—far from it" (17). They call this new number the "national investment in health" (182). Looking at this total sum reversed decades of discussions on the health care paradox. Rather than spending more, Americans might just be spending differently. They found that in 2007, "the United States devoted only 25 percent of gross domestic product to health and social services combined, while such countries as Sweden, France, Austria, Switzerland, and Denmark dedicated about 30 to 33 percent" (17). In short, depending on how you define health and health care, Americans are actually underspending their European counterparts.

Since 1948, the World Health Organization has offered the following definition of health: "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity" (66). In lieu of this positive formulation of health, the United States has placed its financial resources on curing disease through biomedical research and medical intervention. The country continues to do this despite the fact that research consistently demonstrates that social, behavioral, and environmental factors have an enormous effect on an individual's health. As the authors' summarize: "Social and behavioral factors contribute to more than 70 percent of colon cancer and stroke, more than 80 percent of coronary heart disease cases, and more than 90 percent of adult-onset (type 2) diabetes cases" (13). Environmental factors, such as air quality and pesticide intake, compound these issues. Still, Bradley and Taylor argue, such facts have not translated to policy: "Despite the strong evidence about social determinants of health, attention devoted to improving health in the United States has been directed largely at reforming the health care industry" (14). Rather than immediately attacking this issue at the level of policy, Bradley and Taylor walk the reader through the historical, political, and institutional contours of the problem. They do so to offer readers a way to engage with and rethink the way health care is currently defined and discussed.

For this reason, The American Health Care Paradox has as much to offer religious leaders and scholars of religion as it does to those crafting health care policy. In Bradley and Taylor's fourth chapter, "Learning from Abroad," the authors take seriously the way citizens' values concerning the state and community inform the health care systems they tolerate and receive. They argue that the social democracies of Scandinavia—Sweden, Denmark, and Norway—offer the most productive comparison to understand American health care choices and shortcomings. Per capita, these countries spend half of what the United States does on health care, and yet they have more physicians and hospital beds. They also offer health insurance to all of their citizens. More importantly, they consistently get better health outcomes by providing for their citizens' general health and not just their medical bills. In the end, argue Bradley and Taylor, Scandinavian governments "balance ‘upstream' work to keep people healthy through adequate services in the social sphere, with ‘downstream' work of medical care for people after they have become ill" (106). By looking at how national values inform the Scandinavian and American approaches, the authors simultaneously explain the crucial differences between these health care systems and demonstrate how the United States could learn from some of the Scandinavian successes.

Values, Bradley and Taylor argue, remain at the generative center of all policy. Relying on data compiled by the World Values Survey, a network of social scientists conducting interviews on "basic values and beliefs" across the globe, the authors locate a set of shared and divergent values. Interestingly, Americans and Scandinavians share a respect for personal freedom and have "equal faith in competition as a vehicle for progress in modern society" (86). Still, in terms of health care, the differences are more illuminating than the similarities.

One fundamental difference resides in the way citizens understand the purpose of health. Scandinavians, the authors' claim, "view health as a means to an end, rather than simply an end in itself" (103). They pursue health for what it will allow them to do, such as work or take vacation. This persuasion has given local governments in Scandinavia the ability to provide a wide range of services for those taken ill. Rather than treat health outside of a constellation of needs and concerns, they offer medical care along with subsidies for car travel, shopping, and housecleaning. The policy goal is to give citizens the means to live productive lives, not just give citizens access to doctors. In contrast, in the United States, the authors argue, health has become "an end in itself" (103). A public conversation on what health is actually for might aid policy makers in developing more diverse, and less expensive, care options.

Another major difference between the Scandinavian and American approach centers on the central purpose of government. The authors ground their conclusions about the distinct relationship to government in a philosophical discussion of Rousseau's social contract and a historical discussion of the development of the state in Scandinavia and the United States. Bradley and Taylor concede "some may find such topics as the ‘social contract' too abstract for a practical discussion of health care," but, they argue, "collective views about the role of government have far-reaching implications when it comes to the question of who is responsible for promoting health" (88). How much one is willing to give up to the collective, as well as how much trust he or she has in the good will of that collective, directly shapes attitudes about the government's job in distributing social services and health care. Scandinavians tend to be more open than Americans to the government's involvement in redistributing wealth; in particular, they support taxing the wealthy to provide for the poor. The authors connect this value difference to the discrepancy in social welfare spending or "safety net programs," such as housing subsidies and family support. It seems that the United States might be short-changing social welfare spending, and in turn over-financing health care, because of a deficit in trust.

In the end, The American Health Care Paradox poses more questions than it answers. It is not, by any means, a proscriptive policy book. Rather, it is an invitation to rethink the basic building blocks of the American health system; to reframe a conversation obsessed with medical coverage to one capable of thinking about health in its broadest terms. Bradley and Taylor conclude: ". . . we believe that changing the dialogue around health to be holistic and inclusive of nonmedical contributions is paramount to resolving the spend more, get less phenomenon in American health care. Only in the wake of such a shift will scalable and sustainable solutions emerge" (194). While this exceptional study offers dynamic tools to promote such a shift among citizens, its greatest contribution might still be for policy makers. If attitudes toward government funding for health pivot on feelings toward the government itself, it could be crucial for politicians to first make the case for government before making the case for health care. In this respect, The American Health Care Paradox might offer its own way to evaluate the success of the ACA. If it actually works, a major contribution of the ACA would be its ability to boost Americans' faith in government, and to inspire citizens to think about health as a collective endeavor instead of a private purchase.

Tamara Mann, MTS '05, received her doctorate in history from Columbia University and is currently working on a manuscript on the history of old age and Medicare. Her writing has appeared in The Washington Post, The Huffington Post, and My Jewish Learning.